- Email: [email protected]
High performance in healthcare priority setting and resource allocation: A literature- and case study-based framework in the Canadian context
Accepted Manuscript High performance in healthcare priority setting and resource allocation: A literatureand case study-based framework in the Canadian context Neale Smith, Craig Mitton, William Hall, Stirling Bryan, Cam Donaldson, Stuart Peacock, Jennifer L. Gibson, Bonnie Urquhart PII:
S0277-9536(16)30311-2
DOI:
10.1016/j.socscimed.2016.06.027
Reference:
SSM 10700
To appear in:
Social Science & Medicine
Received Date: 18 November 2013 Revised Date:
4 March 2016
Accepted Date: 15 June 2016
Please cite this article as: Smith, N., Mitton, C., Hall, W., Bryan, S., Donaldson, C., Peacock, S., Gibson, J.L., Urquhart, B., High performance in healthcare priority setting and resource allocation: A literatureand case study-based framework in the Canadian context, Social Science & Medicine (2016), doi: 10.1016/j.socscimed.2016.06.027. This is a PDF file of an unedited manuscript that has been accepted for publication. As a service to our customers we are providing this early version of the manuscript. The manuscript will undergo copyediting, typesetting, and review of the resulting proof before it is published in its final form. Please note that during the production process errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain.
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Craig Mitton, PhD Centre for Clinical Epidemiology & Evaluation, and School of Population and Public Health, UBC
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William Hall, MSc (candidate) School of Population and Public Health, UBC
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Neale Smith*, MA, MEDes Centre for Clinical Epidemiology & Evaluation Vancouver Coastal Health Research Institute University of British Columbia 7th floor, 828 W 10th Avenue Vancouver, BC V5Z1M9 Ph: (604) 875-4111 ext 66712 Email: [email protected]
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High Performance in Healthcare Priority Setting and Resource Allocation: Key Elements
Stirling Bryan, PhD Centre for Clinical Epidemiology & Evaluation, and School of Population and Public Health, UBC
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Cam Donaldson, PhD Yunus Centre for Social & Business Health Glasgow Caledonian University
Stuart Peacock, PhD Canadian Centre for Applied Research in Cancer Control (ARCC), and BC Cancer Agency, and School of Population and Public Health, UBC
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Jennifer L. Gibson, PhD Joint Centre for Bioethics and Institute of Health Policy, Management and Evaluation University of Toronto Bonnie Urquhart CGA, MSc Northern Health Authority *Corresponding Author
ACKNOWLEDGMENTS: The authors thank Evelyn Cornelissen, Diane Schmidt, and Iestyn Williams for their feedback on drafts of this paper. The final version was improved substantially due to comments offered by three Journal reviewers. The overall research project benefitted from the important contributions of Alan Davidson, Francois Dionne, and Stuart MacLeod. This project was funded by the Canadian Institutes of Health Research.
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High Performance in Healthcare Priority Setting and Resource Allocation: A Literature- and Case Study-based Framework in the Canadian Context
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ABSTRACT
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Priority setting and resource allocation, or PSRA, are key functions of executive teams in healthcare organizations. Yet decision-makers often base their choices on historical patterns of resource distribution or political pressures. Our aim was to provide leaders with guidance on how to improve PSRA practice, by creating organizational contexts which enable high performance. We carried out in-depth case studies of six Canadian healthcare organizations to obtain from healthcare leaders their understanding of the concept of high performance in PSRA and the factors which contribute to its achievement. Individual and group interviews were carried out (n=62) with senior managers, middle managers and Board members. Site observations and document review were used to assist researchers in interpreting the interview data. Qualitative data were analyzed iteratively with the literature on empirical examples of PSRA practice, in order to develop a framework of high performance in PSRA.
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The framework consists of four domains - structures, processes, attitudes and behaviours, and outcomes - within which are 19 specific elements. The emergent themes derive from case studies in different kinds of health organizations (urban/rural, small/large) across Canada. The elements can serve as a checklist for 'high performance' in PSRA. This framework provides a means by which decision-makers in healthcare might assess their practice and identify key areas for improvement. The findings are likely generalizable, certainly within Canada but also across countries. This work constitutes, to our knowledge, the first attempt to present a full package of elements comprising high performance in health care PSRA.
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KEYWORDS
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Resource allocation; priority setting; healthcare management; high performance; Canada
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INTRODUCTION/BACKGROUND Healthcare decision makers face two main impediments with respect to priority setting and resource allocation, or PSRA. (On how we define key terms in this paper, see Supplemental
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File One: Notes on terminology.) The first is a lack of skills in these endeavours (Lomas,
Veenstra, Woods, 1997; Bate, Donaldson, and Murtagh, 2007) while the second pertains to the organization and culture of healthcare management, where processes, attitudes and incentives
(Mitton and Donaldson, 2003b; Peacock et al., 2010).
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have been shaped by and implicitly continue to support PSRA based on historical patterns
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To address the first challenge, research has focused on means to institute formal PSRA procedures within organizations (Mitton and Donaldson, 2004a). Much less attention has been paid to how different organizational contexts affect the quality of realized PSRA. We have limited knowledge of how barriers and facilitators to successful implementation (e.g., Mitton and
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Donaldson, 2004b; Gibson et al, 2005b; Sibbald et al, 2009) are arrayed as structures, processes and behaviours that would enable ‘high performance’ (see Supplemental File One for more on this concept). While there have been previous studies which proposed systems for evaluating
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resource allocation, there has not previously been a framework which organizes key elements around the concept of high performance. This paper addresses two research questions: ‘How can
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‘high performance’ with respect to health care priority setting be defined’, and ‘can a framework for achieving excellence in priority setting adequately capture relevant aspects of high performance’? We define high performance through the creation of such a framework, rooted in the experiences and wisdom of healthcare leaders in several Canadian organizations. METHODS/APPROACH
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Here, we provide an overview of how this research was conducted; a more detailed description of methods is provided in Supplemental File Two. We reached our conclusions about high performance in PSRA by integrating evidence from qualitative research in six Canadian
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healthcare organizations with the empirical literature. Case studies (Stake, 1995) provided us with detailed descriptions of situated PSRA processes, and their strengths and weaknesses as understood by healthcare leaders. First, we describe case and key informant selection and the
review of the empirical literature on PSRA.
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interview process. Then, we indicate how qualitative analysis proceeded iteratively with our
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We made deliberate effort to include different types of organization, such as individual hospitals and integrated health service delivery authorities; we also sought diversity in terms of budget size (large and small), as well as other factors. (See Table 1 for how these factors were ultimately balanced across cases.) In other words, cases were chosen in order to maximize
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learning (Stake, 1995). One case site in each of six regions across Canada (see Supplemental File One) was selected from among sites which we identified as potentially ‘high performers’ (See Supplemental File Two).
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At each site, we sought to interview members of the senior management team (SMT), a sample of middle managers (those who report directly to a member of the SMT) from a range of
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program areas, and one or two governing Board members. Interviews used a semi-structured guide, including such topics as how respondents personally defined high performance in PSRA, their assessment of current strengths and weaknesses, and whether or not they agreed with the judgment of peers that their organization was a ‘high performer’. Most data collection occurred between February and June 2012; some interviews were conducted after that time due to participant availability or to address specific unanswered
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questions at select sites. Interviews were audiotaped and transcribed with consent; a total of 62 persons participated, with a range of 5-17 persons per site. Ethics approval was obtained by the Behavioural Research Ethics Board at the principal investigator’s institution, as well as local
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REBs from individual case study sites when requested.
Data analysis began with four domains as a starting template (King, 2004). We
postulated, in line with Donabedian’s work on health care quality (1988), that PSRA outcomes
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depend upon institutional structures and organizational processes within which decision makers consider problems and make choices. We also deemed decision maker attitudes and behaviours a
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key determining factor. These four domains are depicted in Figure 1 (and See Supplemental File Two for more details). Beginning with these domains, we identified sub-themes (elements) inductively. These emerging qualitative themes – elements of high performance -- guided our investigation of the literature. That is, we assessed published studies of PSRA practice in other
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jurisdictions to confirm where case study themes were consistent with these larger findings, and to pinpoint areas where case studies and literature might diverge. RESULTS
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Synthesizing across our cases, along with the literature and our own experiences, we are able to describe what appear to be key elements within the four domains of high performance in
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relation to organization-wide PSRA. Table 2 presents each element both in terms of the case study analysis and its coherence with the literature. Supplemental File Three provides additional commentary, for instance noting where our findings fail to reflect or serve to extend existing literature, and where evidence for an element is limited in either our data or the literature. Each element is framed in a normative fashion, e.g., that healthcare organizations ‘will’ or ‘should’ do X in order to achieve high performance in PSRA. We included in the framework only those
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elements which we found in more than one case study through qualitative analysis, and which were corroborated by some previous mention in the larger PSRA literature we reviewed. Beyond this basic level we did not assign ‘weights’ to the frequency with which elements were described
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in informants’ responses. Nuances or interesting interpretive elements could however be derived from description in a single case. This is consistent with qualitative research practice in which the presence or interpretive value of a theme does not depend upon straightforward numerical
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counts (Pope et al, 2000).
As Table 2 and Supplemental File Three suggest, most of the elements identified through
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qualitative analysis have also been identified as relevant to priority setting performance elsewhere in the literature. The outcome elements proved most difficult to construct. One notable divergence between our case studies and the literature is around the outcome of actual reallocation – this was not raised by informants, who appeared to consider that improving
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processes was their most important focus. Nonetheless we retained this, due to its prominence in other research. Neither the literature nor our case studies were able to shed much light upon ultimate outcomes—how to assess whether PSRA processes in fact contribute to the achievement
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of health organization goals and population and client health improvements. Our respondents shared the perception that a culture of improvement is linked to high performance and we
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included this domain, though the literature itself is inconclusive (Scott et al, 2003). In terms of fair process, the absence of an appeals mechanism – a central tenet of A4R (Daniels and Sabin, 2002) – did not seem overly of concern to our informants. Reviewing Table 2, readers will see that case study sites overall judged themselves to be
strong in terms of leadership and desire to be better priority setters and in resisting overt political pressures, but found their efforts to be weaker when it came to effective models of staff and
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public engagement, communications, disinvestment, and ensuring that processes were not overly time- and effort-demanding. Seemingly important elements, but for which we can yet offer relatively little specific guidance for practice, include the nature of leadership, the kinds of
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education and training needed, and the role of a designated PSRA coordinator. Finally, we would suggest that neither the literature or our own research here yet sheds much light on whether or not the factors conducive to high performance would also contribute to the sustainability of
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formal approaches to PSRA over time. DISCUSSION
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This study has proposed a comprehensive set of attributes to define high performance PSRA in health institutions. One strength of these findings is the combination of methods used to ground this descriptive framework, integrating lessons from an international literature with detailed qualitative interviews from decision makers across Canada. Our research sites spanned a
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range of settings with distinct challenges. While much past research has promoted particular techniques, or looked at factors which facilitate or hinder PSRA in individual situations, our efforts here distill characteristics across contexts which seem to matter regardless of
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organizational configurations or models of PSRA practice. This unifies treatment of structures, processes, behaviours and outcomes. Our results thus focused upon common themes. Finding
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substantive areas of divergence between types of site, for instance urban or rural, was not a primary aim of the study; nonetheless we can report that we found no apparent pattern in responses among the different types of site. (This is consistent with our earlier survey work (Smith et al 2013) where approaches to PSRA did not appear to differ between healthcare organizations of different sizes or geographies.) There have been some few past studies which propose systematic ways of assessing PSRA experience. Sibbald et al (2009) propose a
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framework of 10 dimensions, five related to process and five to outcomes. These authors suggested that their research was an “initial attempt to evaluate priority setting decisions in a specific context” and that “future research is required to determine the best combination of
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components” – building on this work, we have adapted many of their dimensions into our model of high performance. Kapiriri and Martin (2009) have offered an approach to priority setting evaluation specific to the context of developing countries. In the UK, a set of 11 competencies
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that would enable ‘world class’ commissioning were developed for Primary Care Trusts, or PCTs (McCafferty et al, 2012). Before these could be widely tested, NHS reforms abolished
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PCTs in favour of Clinical Commissioning Groups, for which a new set of nine resource allocation competencies was created (Russell et al., 2013). These competencies include areas such as communication, ethical judgement, evidence assessment and external communication. According to the authors, “evidence is emerging [that this framework] is being used as a starting
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point to help CCGs reflect on their future needs as resource allocators” (p. 123). These frameworks have considerable overlap with our own. Every organization faced with limited resources has to make choices about what to fund and what not to fund; we expect that while the
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elements underlying good practice for this choice-making may differ to some (limited) degree across jurisdictions, the elements of high performance we have identified through our work in
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Canada could serve at a minimum as a starting point for discussion in other settings as well. The boundaries between the elements are clearly not watertight; depending on how it is
framed, a particular attribute could for instance be seen as a structure, or as a behaviour exhibited within structures or processes. We were more concerned, in this first effort at articulating the idea of high performance in PSRA, with the inclusion of all significant elements than with their precise placement within our framework.Note that our framework includes all the factors we
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have identified as relevant to high performance, without attempting to establish a hierarchy or pattern of relations among them. This should be the subject of additional research. We can envision, for instance, that the absence of certain elements (such as lack of staff engagement due
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to a history of antagonistic interactions between physicians and administrators) might undermine the chances of others (such as a formalized PSRA process) being successfully put in place. This
hoc evaluation of PSRA activities. Limitations.
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suggests that the framework might be used to assess organizational readiness in addition to post
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We acknowledge potential limitations. We used a traditional approach to literature review rather than explicit systematic review techniques. Such reviews can be criticized for being subjective (Rumrill and Fitzgerald, 2001). However our approach identified the most directly applicable evidence for testing our emerging set of elements. Some potentially relevant material,
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possibly unknown to the research team despite its many collective years of experience in the field, may have been missed. We also stuck closely to healthcare PSRA literature; more broadly engaging with other management literatures, some of which are suggested in Table 2, might
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bring additional insights and is worth pursuing in future study. For some topics we were not able to dive as deeply as we would have liked. For example, the literature has given considerable
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attention to public engagement in priority setting, and more recently, the issue of disinvestment is arising with increased frequency. While these are important topics, the structure of this paper does not allow for in depth cover of any given element within the overall framework. The aim of this paper is to present the framework in its entirety. Subsequent research can elaborate upon and refine our understanding of individual elements of high performance, as guided by the needs of healthcare decision makers.
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Finally, as in qualitative research generally, data collection and analysis in this study is fundamentally rooted in the collective experience of the research team. The definition of high performance in PSRA which we have arrived at, presented here in the framework of domains and
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elements, is thus also inextricably bound up with our experiences, knowledge and perspectives. The authors have experience with PSRA in several national contexts, though primarily in the developed world and in countries with publicly-funded universal health insurance models. Most
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of our work is at the meso-level, i.e., resource allocation by and within healthcare organizations, rather than at the political or bedside levels. While mainly health economists, our team is
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multidisciplinary with expertise in ethics and policy research as well. Other researchers and practitioners – with different formative experience and philosophical orientations -- should reflect upon our conclusions against the background of their own situated knowledge. Our survey referral system and use of an Expert Panel to suggest organizations should
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have brought us to sites where there was much to learn. A different group of respondents might have suggested to us different organizations as a starting point. Nonetheless, the emergent themes are present in case studies from different kinds of health organizations (urban/rural,
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small/large) across Canada. Were the sites in which we conducted this work truly high performing organizations? The value of our data should not depend upon solely whether or not
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these organizations could objectively be considered to own that label, since our aim here is to build a grounded definition, not to measure a pre-existing construct. There is no reason to believe that these managers would be less likely than others in similar positions to understand what is required for high performance in PSRA. They do of course have years or decades of practical experience in this field. A different design, for instance, might have looked at ‘low performing’ organizations. We strongly suspect that managers here would point to the same elements as
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being of critical importance; that said, further work with additional organizations across a range of settings is surely needed to determine if the findings resonate with healthcare decision makers more broadly.
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The practical applicability of this work is as a means for decision makers to introspect on their own organization or system and determine where they are lacking across the elements
outlined here. We would theorize that improving practice in areas of perceived weakness would
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lead to a stronger, fairer process for PSRA and better use of limited resources. While this research drew upon experiences of several organizations to identify elements of high
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performance, we did not as part of the research provide explicit assessment of the processes in place at those sites. Rather, we synthesized their input in developing an evaluative tool which has been tested in other settings (Hall et al., 2016). CONCLUSION
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Many health system leaders strive for high performance in management functions like PSRA as much as they do for quality of care. To date however they have had limited practical guidance as to how this might be defined for PSRA or what strategies can be put in place to
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achieve it. In the work presented here, we have combined a detailed investigation of Canadian healthcare organizations whose leaders are deliberately and thoughtfully trying to achieve
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excellence, with careful review of the literature. Most importantly, we have identified a framework of elements which are meaningful and tangible to health system managers. They understand how these features affect their ability to achieve high performance and how, within the limits of their mandate and authority, they can address these.The task is large – to combine structures, processes, and behaviours for the desired outcomes – but not beyond reach.
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REFERENCES Armstrong, K., C. Mitton, B. Carleton, and J. Shoveller. 2008. Drug formulary decision-making in two regional health authorities in British Columbia, Canada. Health Policy 88(2-3):308-316.
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Baker, G.R. and J.-L. Denis. A comparative study of three transformative healthcare systems: lessons for Canada. 2011. Ottawa, ON: Canadian Health Services Research Foundation. Bate, A., C. Donaldson, and M.J. Murtagh. 2007. Managing to manage healthcare resources in the English NHS? What can health economics teach? What can health economics learn? Health Policy 84(2-3):249-261.
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Cohen, D. 1994. Marginal analysis in practice: an alternative to needs assessment for contracting health care. BMJ 309:781-785.
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Daniels, N. and J. Sabin. Setting limits fairly: can we learn to share medical resources? 2002. Oxford: Oxford University Press. Dionne, F., Mitton, C., Smith, N., and Donaldson, C. (2009). Evaluation of the impact of Program Budgeting and Marginal Analysis in Vancouver Island Health Authority. Journal of Health Services Research and Policy, 14(4): 234-42. Donabedian, A. 1988. The quality of care: how can it be assessed? Journal of the American Medical Association 260:1743-8
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Donaldson, C., A. Bate, C. Mitton, F. Dionne, and D. Ruta. 2010. Rational disinvestment. QJM: An Internatinal Journal of Medicine 103(10):801-807. doi: 10.193/qjmed/hcq086
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Donaldson, C., A. Bate, C. Mitton, S. Peacock, and D. Ruta. 2008. Priority setting in the public sector: turning economics into a management process. In Managing to improve public services, edited by J. Hartley, C. Donaldson, J. Skeltcher, and M. Wallace. Cambridge: Cambridge University Press. Gibson, J. L., D.K. Martin, and P.A. Singer. 2005a. Evidence, economics and ethics: resource allocation in health services organizations. Healthcare Quarterly 8(2):50-59.
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Gibson, J. L., D.K. Martin, and P.A. Singer. 2005b. Setting priorities in health care organizations: criteria, processes and parameters of success. BMC Health Services Research 4:25. doi: 10.1186/1472-6963-4-25 Gibson, J.L., C. Mitton, and G. DuBois-Wing. 2011. Priority setting in Ontario's LHINs: ethics and economics in action. Healthcare Quarterly 14(4):35-43. Haas, M., J. Hall, R. Viney, and G. Gallego. 2012. Breaking up is hard to do: why disinvestment in medical technology is harder than investment. Australian Health Review 36:148-152. Hall, W., N. Smith, C. Mitton, J.L. Gibson, and S. Bryan. (2016). An evaluation tool for assessing performance in priority setting and resource allocation: multi-site application to identify strengths and weaknesses. Journal of Health Services Research and Policy 21(1), 15-23.
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Halma, L., C. Mitton, C. Donaldson, and B. West. 2004. Case study on priority setting in rural southern Alberta: keeping the house from blowing in. Canadian Journal of Rural Medicine 9(1):26-36.
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Jan, S. 2000. Institutional considerations in priority setting: transactions cost perspective on PBMA. Health Economics 9(7):631-41. Jan, S. 2003. A perspective on the analysis of credible commitment and myopia in health sector decision making. Health Policy 63:269-278. Kapiriri, L. and D.K. Martin. 2009. Successful priority setting in low and middle income countries: A framework for evaluation. Health Care Analysis 18:129-147.
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Kenny, N. and C. Joffres. 2008. An ethical analysis of international health priority-setting. Health Care Analysis 16: 145-160.
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King, N. 2004. Using templates in the thematic analysis of text. In Essential Guide to Qualitative Methods in Organizational Research, edited by C.Cassell and G.Symon. London: Sage. Lomas, J., G. Veenstra, and J. Woods. 1997. Devolving authority for health care in Canada's provinces: 2. Backgrounds, resources and activities of board members. Canadian Medical Association Journal 156(4):513-520.
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McCafferty, S., I. Williams, D. Hunter, S. Robinson, C. Donaldson, and A. Bate. 2012. Implementing world class commissioning competencies. Journal of Health Services Research and Policy 17(Suppl 1):40-48. Menon, D., T. Stafinski, and D.K. Martin. 2007. Priority-setting for healthcare: who, how, and is it fair? Health Policy 84(2-3):220-233.
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Mitton, C., and C. Donaldson. 2004a. Health care priority setting: principles, practice and challenges. Cost Effectiveness and Resource Allocation 2(3). http://www.resourceallocation.com/content/2/1/3
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Mitton, C., and C. Donaldson. 2004b. Priority setting toolkit: a guide to the use of economics in helathcare decision making. London: BMJ Publishing Group. Mitton, C., and C. Donaldson. 2003a. Resource allocation in health care: health economics and beyond. Health Care Analysis 11(3):245-57. Mitton, C., and C. Donaldson. 2003b.Setting priorities and allocating resources in health regions: lessons from a project evaluating program budgeting and marginal analysis. Health Policy 64:335-348. Mitton, C., and C. Donaldson. 2001. Twenty-five years of program budgeting and marginal analysis in the health sector, 1974-99. Journal of Health Services Research and Policy 6(4):239248.
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Mitton, C., C. Donaldson, H. Waldner, and C. Eagle. 2003. The evolution of PBMA: towards a macro-level priority setting framework for health regions. Health Care Management Science 6:263-269.
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Mitton, C. and S. Patten. 2004. Evidence-based priority-setting: what do the decision-makers think? Journal of Heath Services Research and Policy 9(3):146-152. Mitton, C., S. Patten, and C. Donaldson. 2004. Listening to the decision makers: refinement of macro-level PBMA in Alberta. Applied Health Economics and Health Policy 3(3):143-151. Mitton, C., N. Smith, S. Peacock, B. Evoy, and J. Abelson. 2009. Public participation in health care priority setting: a scoping review. Health Policy 91(3):219-229.
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Mullen, P. 2004. Quantifying priorities in healthcare: transparency or illusion? Health Services Management Research 17(1):47-58.
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Peacock, S. An evaluation of program budgeting and marginal analysis applied in South Australian hospitals. 1998. Melbourne: Center for Health Program Evaluation, Monash University. Peacock, S., C. Mitton, D. Ruta, C. Donaldson, A. Bate, and L. Hedden. 2010. Priority setting in healthcare: towards guidelines for the program budgeting and marginal analysis framework. Expert Rev Pharmacoecon Outcomes Research 10(5):539-552.
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Pope C, Ziebland S, Mays N. 2000. Qualitative research in health care: analyzing qualitative data. BMJ 320;114-116. Robinson, S., H. Dickinson, T. Freeman, B. Rumbold, and I. Williams. 2012a. Structures and processes for priority-setting by health-care funders: a national survey of primary care trusts in England. Health Services Management Research 25:113-130.
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Robinson, S., I. Williams, H. Dickinson, T. Freeman, and B. Rumbold, B. 2012b. Prioritysetting and rationing in health care: evidence from the English experience. Social Science and Medicine 75(12), 2386-2393.
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Rumrill, P.D. Jr, and S.M. Fitzgerald. 2001. Using narrative literature reviews to build a scientific knowledge base. Work 16:165-170. Russell, J., Greenhalgh, T., Lewis, H., MacKenzie, I., Maskrey, N., Montgomery, J., O'Donnell, C. 2013. Addressing the 'postcode lottery' in local resource allocation decisions: a framework for clinical commissioning groups. Journal of the Royal Society for Medicine, 106, (4), 120-123. Ruta, D., C. Mitton, A. Bate, and C. Donaldson. 2005. Programme budgeting and marginal analysis: bridging the divide between doctors and managers. BMJ 330(7506):1501-1503. doi: 10.1136/bmj.330.7506.1501 Sabik, L.M., and R.K. Lie. 2008. Priority setting in health care: lessons from the experiences of eight countries. International Journal for Equity in Health 7(4). doi:10.1186/1475-9276-7-4
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Scott, T., R. Mannion, M. Marshall, and H. Davies. 2003. Does organisational culture influence health care performance? A review of the evidence. Journal of Health Services Research and Policy 8(2):105-117.
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Sibbald, S.L., P.A. Singer, R. Upshur, and D.K. Martin. 2009. Priority setting: what constitutes success? A conceptual framework for successful priority setting. BMC Health Services Research 9(43). doi:10.1186/1472-6963-9-43
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Smith, N., Mitton, C., Bryan, S., Davidson, A., Urquhart, B., Gibson, J.L., Peacock, S., and Donaldson, C. (2013). Decision maker perceptions of resource allocation processes in Canadian health care organizations: a national survey. BMC Health Services Research, 13(247). doi:10.1186/1472-6963-13-247 Stake, R. The art of case research. 1995. Newbury Park, CA: Sage Publications.
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Teng, F., C. Mitton, and J. MacKenzie. 2007. Priority setting in the provincial health services authority: survey of key decision makers. BMC Health Services Research 7(84). doi: 10.1186/1472-6963-7-84. Tsourapas, A. and E. Frew. 2011. Evaluating 'success' in programme budgeting and marginal analysis: a literature review. Journal of Health Services Research and Policy 16(3):177-183.
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Yonek, J., S. Hines, and M. Joshi. A Guide to Achieving High Performance in Multi-Hospital Health Systems. 2010. Chicago, IL: Health Research & Educational Trust.
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TABLE AND FIGURE CAPTIONS Table 1: Distribution of Cases
Figure 1: Domains of High Performance in PSRA
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Table 2: Results
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Sources for Figure 1: Donabedian, 1988; Giddens, 1984; Sanderson, 2001; Scott et al,
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2003
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Behaviours
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•Patterned choices typically made by organizational members, informed by historical experience, which collectively constitute organizational cultures and subcultures. Beliefs and values manifest in the behaviours or actions in which individual actors engage.
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Attitudes/
Processes
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Structures
•A systematic series of actions directed towards a particular result. These are typically formalized but may also be unwritten but agreed upon.
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•Tangible or intangible formalized patterns of interaction and relationships between entities that direct or inhibit organizations’ progress towards collaboratively identified goals.
Outcomes
•Measurable consequences that occur as a result of the PSRA process . Desired outcomes are those for whose achievement members agree to be accountable; however unanticipated negative consequences may also be possible
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Research Highlights
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This research addresses healthcare priority setting and resource allocation (PSRA) This research proposes elements which define high performance in PSRA These elements are derived from case studies and the literature Healthcare managers can assess strengths and areas for improvement
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• • • •
S0277-9536(16)30311-2
DOI:
10.1016/j.socscimed.2016.06.027
Reference:
SSM 10700
To appear in:
Social Science & Medicine
Received Date: 18 November 2013 Revised Date:
4 March 2016
Accepted Date: 15 June 2016
Please cite this article as: Smith, N., Mitton, C., Hall, W., Bryan, S., Donaldson, C., Peacock, S., Gibson, J.L., Urquhart, B., High performance in healthcare priority setting and resource allocation: A literatureand case study-based framework in the Canadian context, Social Science & Medicine (2016), doi: 10.1016/j.socscimed.2016.06.027. This is a PDF file of an unedited manuscript that has been accepted for publication. As a service to our customers we are providing this early version of the manuscript. The manuscript will undergo copyediting, typesetting, and review of the resulting proof before it is published in its final form. Please note that during the production process errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain.
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Craig Mitton, PhD Centre for Clinical Epidemiology & Evaluation, and School of Population and Public Health, UBC
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William Hall, MSc (candidate) School of Population and Public Health, UBC
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Neale Smith*, MA, MEDes Centre for Clinical Epidemiology & Evaluation Vancouver Coastal Health Research Institute University of British Columbia 7th floor, 828 W 10th Avenue Vancouver, BC V5Z1M9 Ph: (604) 875-4111 ext 66712 Email: [email protected]
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High Performance in Healthcare Priority Setting and Resource Allocation: Key Elements
Stirling Bryan, PhD Centre for Clinical Epidemiology & Evaluation, and School of Population and Public Health, UBC
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Cam Donaldson, PhD Yunus Centre for Social & Business Health Glasgow Caledonian University
Stuart Peacock, PhD Canadian Centre for Applied Research in Cancer Control (ARCC), and BC Cancer Agency, and School of Population and Public Health, UBC
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Jennifer L. Gibson, PhD Joint Centre for Bioethics and Institute of Health Policy, Management and Evaluation University of Toronto Bonnie Urquhart CGA, MSc Northern Health Authority *Corresponding Author
ACKNOWLEDGMENTS: The authors thank Evelyn Cornelissen, Diane Schmidt, and Iestyn Williams for their feedback on drafts of this paper. The final version was improved substantially due to comments offered by three Journal reviewers. The overall research project benefitted from the important contributions of Alan Davidson, Francois Dionne, and Stuart MacLeod. This project was funded by the Canadian Institutes of Health Research.
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High Performance in Healthcare Priority Setting and Resource Allocation: A Literature- and Case Study-based Framework in the Canadian Context
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ABSTRACT
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Priority setting and resource allocation, or PSRA, are key functions of executive teams in healthcare organizations. Yet decision-makers often base their choices on historical patterns of resource distribution or political pressures. Our aim was to provide leaders with guidance on how to improve PSRA practice, by creating organizational contexts which enable high performance. We carried out in-depth case studies of six Canadian healthcare organizations to obtain from healthcare leaders their understanding of the concept of high performance in PSRA and the factors which contribute to its achievement. Individual and group interviews were carried out (n=62) with senior managers, middle managers and Board members. Site observations and document review were used to assist researchers in interpreting the interview data. Qualitative data were analyzed iteratively with the literature on empirical examples of PSRA practice, in order to develop a framework of high performance in PSRA.
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The framework consists of four domains - structures, processes, attitudes and behaviours, and outcomes - within which are 19 specific elements. The emergent themes derive from case studies in different kinds of health organizations (urban/rural, small/large) across Canada. The elements can serve as a checklist for 'high performance' in PSRA. This framework provides a means by which decision-makers in healthcare might assess their practice and identify key areas for improvement. The findings are likely generalizable, certainly within Canada but also across countries. This work constitutes, to our knowledge, the first attempt to present a full package of elements comprising high performance in health care PSRA.
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KEYWORDS
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Resource allocation; priority setting; healthcare management; high performance; Canada
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INTRODUCTION/BACKGROUND Healthcare decision makers face two main impediments with respect to priority setting and resource allocation, or PSRA. (On how we define key terms in this paper, see Supplemental
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File One: Notes on terminology.) The first is a lack of skills in these endeavours (Lomas,
Veenstra, Woods, 1997; Bate, Donaldson, and Murtagh, 2007) while the second pertains to the organization and culture of healthcare management, where processes, attitudes and incentives
(Mitton and Donaldson, 2003b; Peacock et al., 2010).
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have been shaped by and implicitly continue to support PSRA based on historical patterns
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To address the first challenge, research has focused on means to institute formal PSRA procedures within organizations (Mitton and Donaldson, 2004a). Much less attention has been paid to how different organizational contexts affect the quality of realized PSRA. We have limited knowledge of how barriers and facilitators to successful implementation (e.g., Mitton and
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Donaldson, 2004b; Gibson et al, 2005b; Sibbald et al, 2009) are arrayed as structures, processes and behaviours that would enable ‘high performance’ (see Supplemental File One for more on this concept). While there have been previous studies which proposed systems for evaluating
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resource allocation, there has not previously been a framework which organizes key elements around the concept of high performance. This paper addresses two research questions: ‘How can
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‘high performance’ with respect to health care priority setting be defined’, and ‘can a framework for achieving excellence in priority setting adequately capture relevant aspects of high performance’? We define high performance through the creation of such a framework, rooted in the experiences and wisdom of healthcare leaders in several Canadian organizations. METHODS/APPROACH
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Here, we provide an overview of how this research was conducted; a more detailed description of methods is provided in Supplemental File Two. We reached our conclusions about high performance in PSRA by integrating evidence from qualitative research in six Canadian
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healthcare organizations with the empirical literature. Case studies (Stake, 1995) provided us with detailed descriptions of situated PSRA processes, and their strengths and weaknesses as understood by healthcare leaders. First, we describe case and key informant selection and the
review of the empirical literature on PSRA.
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interview process. Then, we indicate how qualitative analysis proceeded iteratively with our
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We made deliberate effort to include different types of organization, such as individual hospitals and integrated health service delivery authorities; we also sought diversity in terms of budget size (large and small), as well as other factors. (See Table 1 for how these factors were ultimately balanced across cases.) In other words, cases were chosen in order to maximize
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learning (Stake, 1995). One case site in each of six regions across Canada (see Supplemental File One) was selected from among sites which we identified as potentially ‘high performers’ (See Supplemental File Two).
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At each site, we sought to interview members of the senior management team (SMT), a sample of middle managers (those who report directly to a member of the SMT) from a range of
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program areas, and one or two governing Board members. Interviews used a semi-structured guide, including such topics as how respondents personally defined high performance in PSRA, their assessment of current strengths and weaknesses, and whether or not they agreed with the judgment of peers that their organization was a ‘high performer’. Most data collection occurred between February and June 2012; some interviews were conducted after that time due to participant availability or to address specific unanswered
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questions at select sites. Interviews were audiotaped and transcribed with consent; a total of 62 persons participated, with a range of 5-17 persons per site. Ethics approval was obtained by the Behavioural Research Ethics Board at the principal investigator’s institution, as well as local
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REBs from individual case study sites when requested.
Data analysis began with four domains as a starting template (King, 2004). We
postulated, in line with Donabedian’s work on health care quality (1988), that PSRA outcomes
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depend upon institutional structures and organizational processes within which decision makers consider problems and make choices. We also deemed decision maker attitudes and behaviours a
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key determining factor. These four domains are depicted in Figure 1 (and See Supplemental File Two for more details). Beginning with these domains, we identified sub-themes (elements) inductively. These emerging qualitative themes – elements of high performance -- guided our investigation of the literature. That is, we assessed published studies of PSRA practice in other
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jurisdictions to confirm where case study themes were consistent with these larger findings, and to pinpoint areas where case studies and literature might diverge. RESULTS
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Synthesizing across our cases, along with the literature and our own experiences, we are able to describe what appear to be key elements within the four domains of high performance in
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relation to organization-wide PSRA. Table 2 presents each element both in terms of the case study analysis and its coherence with the literature. Supplemental File Three provides additional commentary, for instance noting where our findings fail to reflect or serve to extend existing literature, and where evidence for an element is limited in either our data or the literature. Each element is framed in a normative fashion, e.g., that healthcare organizations ‘will’ or ‘should’ do X in order to achieve high performance in PSRA. We included in the framework only those
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elements which we found in more than one case study through qualitative analysis, and which were corroborated by some previous mention in the larger PSRA literature we reviewed. Beyond this basic level we did not assign ‘weights’ to the frequency with which elements were described
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in informants’ responses. Nuances or interesting interpretive elements could however be derived from description in a single case. This is consistent with qualitative research practice in which the presence or interpretive value of a theme does not depend upon straightforward numerical
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counts (Pope et al, 2000).
As Table 2 and Supplemental File Three suggest, most of the elements identified through
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qualitative analysis have also been identified as relevant to priority setting performance elsewhere in the literature. The outcome elements proved most difficult to construct. One notable divergence between our case studies and the literature is around the outcome of actual reallocation – this was not raised by informants, who appeared to consider that improving
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processes was their most important focus. Nonetheless we retained this, due to its prominence in other research. Neither the literature nor our case studies were able to shed much light upon ultimate outcomes—how to assess whether PSRA processes in fact contribute to the achievement
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of health organization goals and population and client health improvements. Our respondents shared the perception that a culture of improvement is linked to high performance and we
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included this domain, though the literature itself is inconclusive (Scott et al, 2003). In terms of fair process, the absence of an appeals mechanism – a central tenet of A4R (Daniels and Sabin, 2002) – did not seem overly of concern to our informants. Reviewing Table 2, readers will see that case study sites overall judged themselves to be
strong in terms of leadership and desire to be better priority setters and in resisting overt political pressures, but found their efforts to be weaker when it came to effective models of staff and
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public engagement, communications, disinvestment, and ensuring that processes were not overly time- and effort-demanding. Seemingly important elements, but for which we can yet offer relatively little specific guidance for practice, include the nature of leadership, the kinds of
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education and training needed, and the role of a designated PSRA coordinator. Finally, we would suggest that neither the literature or our own research here yet sheds much light on whether or not the factors conducive to high performance would also contribute to the sustainability of
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formal approaches to PSRA over time. DISCUSSION
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This study has proposed a comprehensive set of attributes to define high performance PSRA in health institutions. One strength of these findings is the combination of methods used to ground this descriptive framework, integrating lessons from an international literature with detailed qualitative interviews from decision makers across Canada. Our research sites spanned a
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range of settings with distinct challenges. While much past research has promoted particular techniques, or looked at factors which facilitate or hinder PSRA in individual situations, our efforts here distill characteristics across contexts which seem to matter regardless of
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organizational configurations or models of PSRA practice. This unifies treatment of structures, processes, behaviours and outcomes. Our results thus focused upon common themes. Finding
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substantive areas of divergence between types of site, for instance urban or rural, was not a primary aim of the study; nonetheless we can report that we found no apparent pattern in responses among the different types of site. (This is consistent with our earlier survey work (Smith et al 2013) where approaches to PSRA did not appear to differ between healthcare organizations of different sizes or geographies.) There have been some few past studies which propose systematic ways of assessing PSRA experience. Sibbald et al (2009) propose a
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framework of 10 dimensions, five related to process and five to outcomes. These authors suggested that their research was an “initial attempt to evaluate priority setting decisions in a specific context” and that “future research is required to determine the best combination of
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components” – building on this work, we have adapted many of their dimensions into our model of high performance. Kapiriri and Martin (2009) have offered an approach to priority setting evaluation specific to the context of developing countries. In the UK, a set of 11 competencies
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that would enable ‘world class’ commissioning were developed for Primary Care Trusts, or PCTs (McCafferty et al, 2012). Before these could be widely tested, NHS reforms abolished
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PCTs in favour of Clinical Commissioning Groups, for which a new set of nine resource allocation competencies was created (Russell et al., 2013). These competencies include areas such as communication, ethical judgement, evidence assessment and external communication. According to the authors, “evidence is emerging [that this framework] is being used as a starting
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point to help CCGs reflect on their future needs as resource allocators” (p. 123). These frameworks have considerable overlap with our own. Every organization faced with limited resources has to make choices about what to fund and what not to fund; we expect that while the
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elements underlying good practice for this choice-making may differ to some (limited) degree across jurisdictions, the elements of high performance we have identified through our work in
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Canada could serve at a minimum as a starting point for discussion in other settings as well. The boundaries between the elements are clearly not watertight; depending on how it is
framed, a particular attribute could for instance be seen as a structure, or as a behaviour exhibited within structures or processes. We were more concerned, in this first effort at articulating the idea of high performance in PSRA, with the inclusion of all significant elements than with their precise placement within our framework.Note that our framework includes all the factors we
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have identified as relevant to high performance, without attempting to establish a hierarchy or pattern of relations among them. This should be the subject of additional research. We can envision, for instance, that the absence of certain elements (such as lack of staff engagement due
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to a history of antagonistic interactions between physicians and administrators) might undermine the chances of others (such as a formalized PSRA process) being successfully put in place. This
hoc evaluation of PSRA activities. Limitations.
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suggests that the framework might be used to assess organizational readiness in addition to post
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We acknowledge potential limitations. We used a traditional approach to literature review rather than explicit systematic review techniques. Such reviews can be criticized for being subjective (Rumrill and Fitzgerald, 2001). However our approach identified the most directly applicable evidence for testing our emerging set of elements. Some potentially relevant material,
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possibly unknown to the research team despite its many collective years of experience in the field, may have been missed. We also stuck closely to healthcare PSRA literature; more broadly engaging with other management literatures, some of which are suggested in Table 2, might
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bring additional insights and is worth pursuing in future study. For some topics we were not able to dive as deeply as we would have liked. For example, the literature has given considerable
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attention to public engagement in priority setting, and more recently, the issue of disinvestment is arising with increased frequency. While these are important topics, the structure of this paper does not allow for in depth cover of any given element within the overall framework. The aim of this paper is to present the framework in its entirety. Subsequent research can elaborate upon and refine our understanding of individual elements of high performance, as guided by the needs of healthcare decision makers.
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Finally, as in qualitative research generally, data collection and analysis in this study is fundamentally rooted in the collective experience of the research team. The definition of high performance in PSRA which we have arrived at, presented here in the framework of domains and
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elements, is thus also inextricably bound up with our experiences, knowledge and perspectives. The authors have experience with PSRA in several national contexts, though primarily in the developed world and in countries with publicly-funded universal health insurance models. Most
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of our work is at the meso-level, i.e., resource allocation by and within healthcare organizations, rather than at the political or bedside levels. While mainly health economists, our team is
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multidisciplinary with expertise in ethics and policy research as well. Other researchers and practitioners – with different formative experience and philosophical orientations -- should reflect upon our conclusions against the background of their own situated knowledge. Our survey referral system and use of an Expert Panel to suggest organizations should
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have brought us to sites where there was much to learn. A different group of respondents might have suggested to us different organizations as a starting point. Nonetheless, the emergent themes are present in case studies from different kinds of health organizations (urban/rural,
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small/large) across Canada. Were the sites in which we conducted this work truly high performing organizations? The value of our data should not depend upon solely whether or not
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these organizations could objectively be considered to own that label, since our aim here is to build a grounded definition, not to measure a pre-existing construct. There is no reason to believe that these managers would be less likely than others in similar positions to understand what is required for high performance in PSRA. They do of course have years or decades of practical experience in this field. A different design, for instance, might have looked at ‘low performing’ organizations. We strongly suspect that managers here would point to the same elements as
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being of critical importance; that said, further work with additional organizations across a range of settings is surely needed to determine if the findings resonate with healthcare decision makers more broadly.
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The practical applicability of this work is as a means for decision makers to introspect on their own organization or system and determine where they are lacking across the elements
outlined here. We would theorize that improving practice in areas of perceived weakness would
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lead to a stronger, fairer process for PSRA and better use of limited resources. While this research drew upon experiences of several organizations to identify elements of high
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performance, we did not as part of the research provide explicit assessment of the processes in place at those sites. Rather, we synthesized their input in developing an evaluative tool which has been tested in other settings (Hall et al., 2016). CONCLUSION
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Many health system leaders strive for high performance in management functions like PSRA as much as they do for quality of care. To date however they have had limited practical guidance as to how this might be defined for PSRA or what strategies can be put in place to
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achieve it. In the work presented here, we have combined a detailed investigation of Canadian healthcare organizations whose leaders are deliberately and thoughtfully trying to achieve
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excellence, with careful review of the literature. Most importantly, we have identified a framework of elements which are meaningful and tangible to health system managers. They understand how these features affect their ability to achieve high performance and how, within the limits of their mandate and authority, they can address these.The task is large – to combine structures, processes, and behaviours for the desired outcomes – but not beyond reach.
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REFERENCES Armstrong, K., C. Mitton, B. Carleton, and J. Shoveller. 2008. Drug formulary decision-making in two regional health authorities in British Columbia, Canada. Health Policy 88(2-3):308-316.
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Baker, G.R. and J.-L. Denis. A comparative study of three transformative healthcare systems: lessons for Canada. 2011. Ottawa, ON: Canadian Health Services Research Foundation. Bate, A., C. Donaldson, and M.J. Murtagh. 2007. Managing to manage healthcare resources in the English NHS? What can health economics teach? What can health economics learn? Health Policy 84(2-3):249-261.
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Cohen, D. 1994. Marginal analysis in practice: an alternative to needs assessment for contracting health care. BMJ 309:781-785.
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Daniels, N. and J. Sabin. Setting limits fairly: can we learn to share medical resources? 2002. Oxford: Oxford University Press. Dionne, F., Mitton, C., Smith, N., and Donaldson, C. (2009). Evaluation of the impact of Program Budgeting and Marginal Analysis in Vancouver Island Health Authority. Journal of Health Services Research and Policy, 14(4): 234-42. Donabedian, A. 1988. The quality of care: how can it be assessed? Journal of the American Medical Association 260:1743-8
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Donaldson, C., A. Bate, C. Mitton, F. Dionne, and D. Ruta. 2010. Rational disinvestment. QJM: An Internatinal Journal of Medicine 103(10):801-807. doi: 10.193/qjmed/hcq086
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Donaldson, C., A. Bate, C. Mitton, S. Peacock, and D. Ruta. 2008. Priority setting in the public sector: turning economics into a management process. In Managing to improve public services, edited by J. Hartley, C. Donaldson, J. Skeltcher, and M. Wallace. Cambridge: Cambridge University Press. Gibson, J. L., D.K. Martin, and P.A. Singer. 2005a. Evidence, economics and ethics: resource allocation in health services organizations. Healthcare Quarterly 8(2):50-59.
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Gibson, J. L., D.K. Martin, and P.A. Singer. 2005b. Setting priorities in health care organizations: criteria, processes and parameters of success. BMC Health Services Research 4:25. doi: 10.1186/1472-6963-4-25 Gibson, J.L., C. Mitton, and G. DuBois-Wing. 2011. Priority setting in Ontario's LHINs: ethics and economics in action. Healthcare Quarterly 14(4):35-43. Haas, M., J. Hall, R. Viney, and G. Gallego. 2012. Breaking up is hard to do: why disinvestment in medical technology is harder than investment. Australian Health Review 36:148-152. Hall, W., N. Smith, C. Mitton, J.L. Gibson, and S. Bryan. (2016). An evaluation tool for assessing performance in priority setting and resource allocation: multi-site application to identify strengths and weaknesses. Journal of Health Services Research and Policy 21(1), 15-23.
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Halma, L., C. Mitton, C. Donaldson, and B. West. 2004. Case study on priority setting in rural southern Alberta: keeping the house from blowing in. Canadian Journal of Rural Medicine 9(1):26-36.
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Jan, S. 2000. Institutional considerations in priority setting: transactions cost perspective on PBMA. Health Economics 9(7):631-41. Jan, S. 2003. A perspective on the analysis of credible commitment and myopia in health sector decision making. Health Policy 63:269-278. Kapiriri, L. and D.K. Martin. 2009. Successful priority setting in low and middle income countries: A framework for evaluation. Health Care Analysis 18:129-147.
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Kenny, N. and C. Joffres. 2008. An ethical analysis of international health priority-setting. Health Care Analysis 16: 145-160.
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King, N. 2004. Using templates in the thematic analysis of text. In Essential Guide to Qualitative Methods in Organizational Research, edited by C.Cassell and G.Symon. London: Sage. Lomas, J., G. Veenstra, and J. Woods. 1997. Devolving authority for health care in Canada's provinces: 2. Backgrounds, resources and activities of board members. Canadian Medical Association Journal 156(4):513-520.
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McCafferty, S., I. Williams, D. Hunter, S. Robinson, C. Donaldson, and A. Bate. 2012. Implementing world class commissioning competencies. Journal of Health Services Research and Policy 17(Suppl 1):40-48. Menon, D., T. Stafinski, and D.K. Martin. 2007. Priority-setting for healthcare: who, how, and is it fair? Health Policy 84(2-3):220-233.
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Mitton, C., and C. Donaldson. 2004a. Health care priority setting: principles, practice and challenges. Cost Effectiveness and Resource Allocation 2(3). http://www.resourceallocation.com/content/2/1/3
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Mitton, C., and C. Donaldson. 2004b. Priority setting toolkit: a guide to the use of economics in helathcare decision making. London: BMJ Publishing Group. Mitton, C., and C. Donaldson. 2003a. Resource allocation in health care: health economics and beyond. Health Care Analysis 11(3):245-57. Mitton, C., and C. Donaldson. 2003b.Setting priorities and allocating resources in health regions: lessons from a project evaluating program budgeting and marginal analysis. Health Policy 64:335-348. Mitton, C., and C. Donaldson. 2001. Twenty-five years of program budgeting and marginal analysis in the health sector, 1974-99. Journal of Health Services Research and Policy 6(4):239248.
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Mitton, C., C. Donaldson, H. Waldner, and C. Eagle. 2003. The evolution of PBMA: towards a macro-level priority setting framework for health regions. Health Care Management Science 6:263-269.
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Mitton, C. and S. Patten. 2004. Evidence-based priority-setting: what do the decision-makers think? Journal of Heath Services Research and Policy 9(3):146-152. Mitton, C., S. Patten, and C. Donaldson. 2004. Listening to the decision makers: refinement of macro-level PBMA in Alberta. Applied Health Economics and Health Policy 3(3):143-151. Mitton, C., N. Smith, S. Peacock, B. Evoy, and J. Abelson. 2009. Public participation in health care priority setting: a scoping review. Health Policy 91(3):219-229.
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Mullen, P. 2004. Quantifying priorities in healthcare: transparency or illusion? Health Services Management Research 17(1):47-58.
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Peacock, S. An evaluation of program budgeting and marginal analysis applied in South Australian hospitals. 1998. Melbourne: Center for Health Program Evaluation, Monash University. Peacock, S., C. Mitton, D. Ruta, C. Donaldson, A. Bate, and L. Hedden. 2010. Priority setting in healthcare: towards guidelines for the program budgeting and marginal analysis framework. Expert Rev Pharmacoecon Outcomes Research 10(5):539-552.
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Pope C, Ziebland S, Mays N. 2000. Qualitative research in health care: analyzing qualitative data. BMJ 320;114-116. Robinson, S., H. Dickinson, T. Freeman, B. Rumbold, and I. Williams. 2012a. Structures and processes for priority-setting by health-care funders: a national survey of primary care trusts in England. Health Services Management Research 25:113-130.
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Robinson, S., I. Williams, H. Dickinson, T. Freeman, and B. Rumbold, B. 2012b. Prioritysetting and rationing in health care: evidence from the English experience. Social Science and Medicine 75(12), 2386-2393.
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Rumrill, P.D. Jr, and S.M. Fitzgerald. 2001. Using narrative literature reviews to build a scientific knowledge base. Work 16:165-170. Russell, J., Greenhalgh, T., Lewis, H., MacKenzie, I., Maskrey, N., Montgomery, J., O'Donnell, C. 2013. Addressing the 'postcode lottery' in local resource allocation decisions: a framework for clinical commissioning groups. Journal of the Royal Society for Medicine, 106, (4), 120-123. Ruta, D., C. Mitton, A. Bate, and C. Donaldson. 2005. Programme budgeting and marginal analysis: bridging the divide between doctors and managers. BMJ 330(7506):1501-1503. doi: 10.1136/bmj.330.7506.1501 Sabik, L.M., and R.K. Lie. 2008. Priority setting in health care: lessons from the experiences of eight countries. International Journal for Equity in Health 7(4). doi:10.1186/1475-9276-7-4
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Scott, T., R. Mannion, M. Marshall, and H. Davies. 2003. Does organisational culture influence health care performance? A review of the evidence. Journal of Health Services Research and Policy 8(2):105-117.
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Sibbald, S.L., P.A. Singer, R. Upshur, and D.K. Martin. 2009. Priority setting: what constitutes success? A conceptual framework for successful priority setting. BMC Health Services Research 9(43). doi:10.1186/1472-6963-9-43
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Smith, N., Mitton, C., Bryan, S., Davidson, A., Urquhart, B., Gibson, J.L., Peacock, S., and Donaldson, C. (2013). Decision maker perceptions of resource allocation processes in Canadian health care organizations: a national survey. BMC Health Services Research, 13(247). doi:10.1186/1472-6963-13-247 Stake, R. The art of case research. 1995. Newbury Park, CA: Sage Publications.
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Teng, F., C. Mitton, and J. MacKenzie. 2007. Priority setting in the provincial health services authority: survey of key decision makers. BMC Health Services Research 7(84). doi: 10.1186/1472-6963-7-84. Tsourapas, A. and E. Frew. 2011. Evaluating 'success' in programme budgeting and marginal analysis: a literature review. Journal of Health Services Research and Policy 16(3):177-183.
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Yonek, J., S. Hines, and M. Joshi. A Guide to Achieving High Performance in Multi-Hospital Health Systems. 2010. Chicago, IL: Health Research & Educational Trust.
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TABLE AND FIGURE CAPTIONS Table 1: Distribution of Cases
Figure 1: Domains of High Performance in PSRA
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Table 2: Results
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Sources for Figure 1: Donabedian, 1988; Giddens, 1984; Sanderson, 2001; Scott et al,
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2003
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Behaviours
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•Patterned choices typically made by organizational members, informed by historical experience, which collectively constitute organizational cultures and subcultures. Beliefs and values manifest in the behaviours or actions in which individual actors engage.
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Attitudes/
Processes
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Structures
•A systematic series of actions directed towards a particular result. These are typically formalized but may also be unwritten but agreed upon.
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•Tangible or intangible formalized patterns of interaction and relationships between entities that direct or inhibit organizations’ progress towards collaboratively identified goals.
Outcomes
•Measurable consequences that occur as a result of the PSRA process . Desired outcomes are those for whose achievement members agree to be accountable; however unanticipated negative consequences may also be possible
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Research Highlights
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This research addresses healthcare priority setting and resource allocation (PSRA) This research proposes elements which define high performance in PSRA These elements are derived from case studies and the literature Healthcare managers can assess strengths and areas for improvement
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• • • •